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December 2016 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 4 Texas Health Steps (THSteps) Dental : 4.2 Services, Benefits, Limitations, and Prior Authorization : 4.2.25 Dental Therapy Under General Anesthesia

Providers must comply with TSBDE Rules and Regulations, Title 22 TAC, Part 5, Chapter 110, §§110.6 –110.10. Any anesthesia type services are paid only to the provider. The dental provider is responsible for determining whether a client meets the minimum criteria necessary for receiving general anesthesia. A local anesthesia fee is not paid in addition to other restorative, operative, or surgical procedure fees.
Prior authorization is required for the use of general anesthesia while rendering treatment (to include the anesthesia fee and the facility fee), regardless of place of service, for a client who does not meet the requirements of the “Criteria for Dental Therapy Under General Anesthesia” (22 point threshold) and the “Criteria for Dental Therapy Under General Anesthesia, Attachment 1” forms. Supporting documentation, including the appropriate narrative, must be submitted to TMHP for prior authorization. Prior authorization is required for medically necessary dental general anesthesia that exceeds once per six months, per client, per provider. The dental provider is responsible for obtaining prior authorization for the services performed under general anesthesia. Hospitals, ASCs, and anesthesiologists must obtain the prior authorization number from the dental provider.
Refer to:
Criteria for Dental Therapy Under General Anesthesia on the TMHP website at Dental rehabilitation or restoration services requiring general anesthesia are performed in an outpatient facility.
Surgical services related to THSteps dental services requiring general anesthesia must be coded as follows:
Procedure code 41899 with modifier EP is for the facility to use on the claim form. Procedure code 41899 does not require prior authorization for ASCs and Hospital-based Ambulatory Surgical Centers (HASCs).
The claim forms used are the CMS-1500 or the UB-04 CMS-1450 paper claim forms. The examining physician, anesthesiologist, hospital, ASC, or HASC must submit claims to TMHP separately for the medical and facility components of their services.
Refer to:

Texas Medicaid & Healthcare Partnership
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